[Resolved]  Birla Sun Life Health Plan Of Birla Sun Life Insurance Co. Ltd. — Settlement of my claim # MUMBSCLF0902480 Under Policy #[protected] of Birla Sun Life Health Plan of Birla Sun Life Insurance Co. Ltd.

Sir,
I Want to draw your attention as here under:-

1- That, I have been appiled to Birla Sun life Insurance Co. Ltd. to purchase 3 units value Rs. 300000 of thair Health Plan vide application # H 18313111 along with our cheque # 594531 for Rs.15664 dated 24.11.2008 payable at Canara Bank, Azamgarh.

2- That, My Application has been accepted by the said company and Contract Paper i.e. Policy #[protected] dated 28.01.09 has been issued in my favoure.

3-That,on sep.06 2009 I have feel seviour pain in my both hips joints, My friend Anand Mishra told me that his relative is a Ortho Doctor in Vivekanand Polyclinic, Lucknow. On Sep.07 I went to Lucknow and contact senior Ortho Dr. Sandeep Kapoor, he examined me and diagnose SECONDARY OSTEOARTHRITIS BOTH HIPS and advice surgery treatment of BILATERAL TOTAL HIP ARTHROPLASTY (T.H.R.)

4-That, I consult with my family members regarding operation and financial matter. After acceptance and consent of my family members I have been admited on Sep.11.2009 in Vivekanand Polyclinic, Lucknow.

5-That, my son RAHUL has been told me, that you have a Health Policy of Birla Sun life Insurance Co. Ltd. The Surgery you have undergon is covered under the policy so he had informed to TTK Healthcare TPA Pvt. Ltd. on 11.09.2009 regarding my hospitalisation by e-mail. On the same day TTK reply by e-mail and give us a ticket No TTK CRM # 170188 for further correspondence. But non has visit from TTK OR BSLI Co. Ltd. during my hospitalisation.

6-That, I have been operated on 13.09.09 and my both hip joints have been Implanted i.e THR and discharged from the hospital on 25.09.09

7-That, as per Annexure 1 serial # 27 printed on page # 9 shows that “Total Hip Replacement is covered under grade 2 covered surgeries and payable under Benefit Provisions 1(a)”

8-That, I have submitted claim form (form # 9) by speed post to TTK Health Care New Delhi office & Mumbai office along with all the enclosers.

9-That, I have received an undated letter regarding my claim on 15.11.09 from TTK Health Care TPA Pvt. Ltd. by which they have reject my claim by the reason given below.
“As total Hip Replacement is not payable within the first three years from the policy commencement date. Hence the claim is not payable as per policy term & conditions.”

After receiving the above said rejection letter I have gone through the policy benefit provisions which shows a waiting period as follows.

“ The Policy has a waiting period of 90 days,meaning that only claims due to accidental injuries will be admitted during the 90 days immediately following the policy effective date as shown in your policy detail. This waiting period will however be waived and not applied to any BSLI health plan purchased upon exercising the guaranteed insurability health benefit.” It means after 90 days other policy holder can file claim and avail it.

10-That, my policy has effected from 28.01.09 and expiry date is 28.01.2012 with a term of 3 years and I have been admitted on 11.09.09 (about after 225 days) from the date of Commencement of the said policy. So I can not understood how they rejected my claim. Again I send a letter on 25.11.09 by speed post and a copy of letter by e-mail on 24.11.09 to TTK Health Care TPA Pvt. Ltd. for review and reconsider my claim. But they have rejected again on 11.12.09 by thair letter .
11-That, the term of policy is only for 3 years then how it is possible to avail the claim after expiry of the policy as the reason shows in the rejection letter.

12-That, as per benefit provisions 1(a) the benefit amount per health insurance unit is Rs. 50000 per unit under grade 2 covered surgery.I have purchased 3 units i.e. Rs Three Lakhs & according the above provisions my claim must be payable Rs. 50000 X 3 units i.e. Rs 150000 (One lakh fifty thousands) .

13-That, Your Honour is requested by the perusal of the document attached here with and provision of the policy, please settle my claim and pass suitable order for justice, so justice be done.

Thanking You


(Ramesh Chandra Agrawal)
Claimant / Applicant
256, Raidopur Nai Basti,
Azamgarh (U.P.) 276001
Ph:[protected],224121
Mob: [protected]